What is the current management of acetabulum (pelvic socket) fractures?

Current Management of Acetabular Fractures

The current management of acetabular fractures involves surgical treatment for most displaced or unstable fractures, with open reduction and internal fixation (ORIF) being the standard of care to restore joint congruity and stability, which is essential for optimal functional outcomes and reduced morbidity.

Initial Assessment and Classification

• Comprehensive radiographic evaluation is essential to evaluate bone integrity before making surgical decisions 1
• CT scan allows comprehensive diagnosis of pelvic lesions, including bone lesions and associated injuries 1
• Fractures are commonly classified using the Letournel classification system to guide treatment decisions 2
• Recent trends show a significant rise in anterior column-based fractures, while other fracture patterns have decreased over time 3

Indications for Surgery

• Displaced fractures in the weight-bearing area of the acetabulum generally require ORIF 4
• Unstable fractures require stabilization to limit expansion of pelvic hematoma 1
• Anatomic reduction is critical for optimal outcomes, as reduction quality strongly correlates with clinical results 2
• Early operative treatment in geriatric patients has been suggested to reduce pain and allow earlier mobilization 5

Surgical Approaches

• The Kocher-Langenbeck and Ilioinguinal approaches remain the major surgical approaches used 3
• The Anterior Intra-Pelvic approach has become relatively common in recent years 3
• Modified Kocher-Langenbeck approach can be used for select posterior wall fractures to preserve soft tissue and vascularity 6
• Choice of surgical approach depends on fracture pattern and surgeon experience 3

Surgical Techniques

• For periarticular fractures, prosthetic replacement can provide predictable pain relief and return to ambulatory status 1
• Stabilization of acetabular disease can be achieved with variations of hip replacement, including curettage of the tumor, protrusio cup, cement, and pin or screw fixation 1
• For complex acetabular fractures, external fixation can be performed using a Ganz clamp or an anterior pelvic external fixator 1
• Minimally invasive techniques including percutaneous cementoplasty and osteosynthesis are options for patients with limited life expectancy or unfit for major surgery 1

Postoperative Management

• Most common rehabilitation protocol includes isometric quadriceps and abductor strengthening exercises starting on the first postoperative day 2
• Passive hip movement typically begins 1-3 days postoperatively, with active hip movement ranging from the first postoperative day to 4 weeks 2
• Partial weight-bearing with walker or crutches is typically permitted from 1 to 12 weeks after surgery 2
• Full weight-bearing is generally allowed at the end of 3 months, depending on fracture healing 2
• Recent evidence suggests that accelerated rehabilitation protocols with early weight-bearing may not increase complications 2

Special Considerations for Open Pelvic Fractures

• Open pelvic fractures are rare (1.7% of all pelvic fractures) but have poor prognosis with mortality exceeding 50% 1
• Management priorities include bleeding control, cleaning and debridement of the wound, treatment of associated lesions, and treatment of the pelvic fracture 1
• These complex injuries should be managed in specialized referral centers due to their complexity and need for multidisciplinary approach 1
• Embolization can be used in addition to surgery for hemostasis in open pelvic fractures 1

Complications and Outcomes

• Post-traumatic osteoarthritis remains the major complication, with 16.9% of cases developing severe changes by 44 months 3
• Heterotopic ossification is a common complication 3
• There has been a substantial drop in iatrogenic nerve damage, particularly to the sciatic nerve, in recent years 3
• In elderly patients, all-cause mortality and in-hospital complications remain high even with operative treatment 5
• The rate of secondary conversion to total hip arthroplasty is approximately 12.4% 5

Management Algorithm Based on Fracture Type

• For non-displaced or minimally displaced fractures: Consider non-operative management with protected weight-bearing 4
• For displaced fractures in weight-bearing areas: ORIF is recommended 4
• For complex or comminuted fractures: Consider specialized approaches or total hip arthroplasty depending on patient factors 1
• For elderly patients with fragility fractures: Consider patient's overall health status, as mortality remains high regardless of treatment approach 5

Pitfalls and Caveats

• Surgery should be performed by experienced surgeons as these are complex and demanding procedures 4
• Poor results are typically related to residual fracture displacement or perioperative complications 4
• Hospital-acquired infections are common (17.6%), especially in operatively treated patients 5
• Thromboembolic events and delirium occur in approximately 3.4% of patients 5
• In-hospital mortality is approximately 5.7%, highlighting the severity of these injuries 5